2.0 Analysis 2.1 Method of Navigation The master of the BRIERMIST had on board the navigation instruments and communication equipment he needed to navigate safely. The precision of the position and speed information given by the master at 1347 suggests that the position was a GPS or Loran C reading. The distance of 10.76 M from Rimouski also suggests a reading from a very precise navigation instrument such as GPS or radar. The sinking cannot be attributed to a lack of navigation equipment. 2.2 Decision to Cross On the morning of 27 November 1998, after stopping overnight at the pilot station wharf, the master continued his voyage, believing that the crossing would be made without too much of a problem. At the onset, there was nothing to suggest that the vessel would not complete the voyage. Because the wind was north-westerly, the waves were not as high near the shore as offshore. The master had confidence in his vessel, which was reputed to have a very strong hull. Also, one crew member had a toothache, and he had an appointment with a dentist in Rimouski at 1500. 2.3 Reconstruction of the Vessel's Route Staff at the MCTS centre observed the vessel leaving the north shore heading for le du Bic, but they lost sight of her in snow flurries a few miles offshore. At 0938, the master reported that he expected to arrive in Rimouski at about 1430. At about 1230, during a telephone call to his home, he said that the voyage was going well. However, at about 1330, during a call to his agent in Rimouski, he stated that waves were washing over the vessel and that speed was reduced. He then indicated that he expected to arrive at about 1500, but he did not mention if he intended to change routes. Finally, according to the position given at 1347, the vessel was 10.76 M from Rimouski, at 4828.29' N and 06846.81' W (see the route followed in Appendix A). 2.4 Wind Direction and Wave Height The MCTS centre log indicates that, at 0745 on November 27, the winds were from the north at 15 to 20 knots. Although the winds had been easterly the day before, the weather data taken at le Rouge and on board vessels in the area clearly indicate that the wind had shifted to the west-north-west during the morning. The MCTS centre MTR on duty seems to have forgotten that the wind had changed direction when he asked the master whether the wind was still easterly in his area. However, this confusion had no repercussions for the operator of the first vessel on scene to search the area. When the vessel left the Les Escoumins pilot station, the waves were not as high as they had been the day before, because the wind had turned to the north-west. As the vessel proceeded to cross the river, the effect of the wind on the waves increased. When the vessel reached the shallower section of the Laurentian Channel, with a depth of 20 to 30 m, the wave amplitude may have been increased by the rise in the sea bottom. Also, the ebb tide amplified the turbulence of the waves and the swell. While the vessel was navigating in a rough sea, the sea washed over the after deck, and downflooded into the hold. 2.5 Fish Hold and Lazaret Covers The two fibreglassed wood covers used to close the main fish hold hatch were simply placed on the hatch coaming flange. Because there was no permanent securing system to prevent the hatch covers from moving, routine practice on the BRIERMIST was not to secure them. One of the two covers was found on the south shore 100 km downstream from the position of the sinking. It is possible that the movement of water in the hold or a breaking wave raised these covers and caused the hold to be flooded. However, the covers could also have floated free as the vessel sank. Also, the four after deck scuttles were probably not all watertight: available information indicates that, when the crew washed the deck, water passed through at least one of these scuttles into the fish hold. Thus, there was no truly watertight device for the hold openings, and despite repeated inspections, no one took action to make these access hatches comply with the existing regulations. The communications with MCTS did not mention the lazaret manhole being open. The master mentioned that there was water in the lazaret and in the fish hold. Those interviewed reported that there were two one-inch drainage holes between the lazaret and the fish hold. This could explain the movement of water between the two compartments. 2.6 Hold Flooding Detection The first vessel to reach the scene of the sinking estimated that the wind was north-west at up to 25 knots, and that the waves were 2 to 3 m high. Such conditions were conducive to flooding of the after deck, because on the BRIERMIST, it was not uncommon to find a foot of water on the deck in 20- to 25-knot winds. Also, in foul weather, the vessel was likely to take some time to drain the water retained on the after deck. The fact that there was water in the afterpeak and the fish hold suggests that some of the deck scuttles were not completely watertight, and the water on the deck may have leaked in over a period of five hours or more. Initially, the water could have entered through the gap between the two main hold hatch covers and the non-watertight seal of at least one of the four scuttles on the deck. Since the vessel was not equipped with a water level detector in the fish hold, it would have been some time before the crew realized that water was entering the compartment. As the master did not mention any water ingress during the 1230 and 1330 telephone conversations, the flooding was probably gradual before 1330. At 1340, he said that the sea was washing over the vessel and that there was a foot of water on the deck. Under those conditions, the hatch covers could have become dislodged. Because the two covers were not secured nor watertight, they were likely to open. While the hold was filling with water, the vessel would have settled further by the stern. Breaking seas must have washed over the after deck and over the main fish hold opening. Small fishing vessels like the BRIERMIST are not required to have a water level detector in the fish hold. Therefore, there was no alarm to warn the crew in the wheel-house of the flooding. When the master realized that the vessel was taking on water, he started up the bilge pumping system, but to no avail. 2.7 Regulations and Inspection Program Since she was built in 1981, the BRIERMIST had been inspected five times by TCMS inspectors. Despite this, the hatch covers had not been modified to comply with the safety standards. The former and new owners had not considered it necessary to modify the hold closure system. After purchasing the vessel in February 1998, the master-owner carried out a number of repairs, and he did not hesitate to acquire equipment he deemed useful or necessary for the safety of the vessel. However, he had not replaced the main hatch covers, and apparently no one on board thought that this could be a serious hazard. Many small fishing vessels in the Atlantic region are equipped with hold hatch covers similar to those on the BRIERMIST. Canadian regulations governing hold closure systems are found in the Small Fishing Vessel Inspection Regulations. Subsection 23(2) dealing with fish hold hatches states that they must be provided with efficient means for battening them down and making them watertight. This was not the case on the BRIERMIST, and over the 17 years the vessel was in service, no one saw the need to modify the closure system to make the hold watertight. 2.8 Distress Signals At no time did the master state that he was in distress, nor did he clearly ask for assistance. No distress message was officially transmitted but the precarious situation of the BRIERMIST indicated that she would be facing serious problems. After assessing the situation, the MTR alerted the Qubec MRSC. Like most small fishing vessels, the BRIERMIST was not required to carry an EPIRB. Canadian regulations do not require small fishing vessels like the BRIERMIST to carry EPIRBs. 2.9 Abandonment of the Vessel Although the master knew that the vessel was taking on water for some time and was having pumping problems, he hoped to be able to reach the shore without having to abandon the vessel in bad weather and did not declare an emergency. Given that one seaman was found with a lifebuoy and the other partly dressed in a PFD, and that the liferaft and several other life-saving appliances were not found, the three remaining crew members were likely unable to clear the sinking vessel wearing the proper life-saving equipment. During the abandonment, one seaman took the lifebuoy which was equipped with a light and a rope about one metre long. He attached this light to his arm to be more visible. The TSB Engineering Laboratory analysis found that the filament of the 2.5-volt, 0.7-ampere bulb was intact and that the light was in good operating condition. Its magnesium/silver chloride battery is activated by contact with water, and it provides about two hours of light. There is every reason to believe that the light was operating when the ship was abandoned, as it was immersed in salt water. Because the fish hold was downflooded first, the vessel probably settled by the stern, and the trim increased as water flooded the vessel. Once the reserve buoyancy was lost, the vessel probably sank by the stern or capsized after losing stability. 2.10 Personal Flotation Devices (PFDs) The three missing seamen may have gone down with the vessel or been drowned on abandoning her without lifejackets or nose-to-toes PFDs. One of the seamen who was recovered was wearing a floater suit pulled only to the waist. The other victim did not have a floater suit. Without a nose-to-toes PFD, no one could survive for more than a few minutes in the cold waters of the St. Lawrence River. The regulations governing fishing vessels over 150 gross tons require the carriage of a sufficient number of immersion suits for the ship's entire complement. However, these regulations do not apply to small fishing vessels under 150 gross tons. The BRIERMIST was not required to provide immersion suits for the crew members on board. 2.11 Training Except for the master, none of the four other seamen held a certificate or had taken any training courses for fishermen or MED training. In situations involving similar weather conditions with the potential to have to abandon a vessel, being trained in the application of emergency procedures would enhance the probability of survival of the crew. 2.12 Crew According to the coroner's report, the results of the analyses to detect the presence of alcohol or drugs in the blood of the two recovered victims were negative. The vessel stopped at the pilot station wharf overnight on November 27, giving the crew the opportunity to shower and rest for about six hours before returning to sea. 3.0 Conclusions 3.1 Findings as to Causes and Contributing Factors As the vessel crossed the river, the effect of the north-west wind over the more open water increased the height of the waves from that experienced near the north shore. The BRIERMIST was sailing in a 25-knot north-west wind and seas broke on the deck at such a rate that the vessel was unable to clear the water. As the BRIERMIST settled, she became more vulnerable to shipping seas. Water was able to enter through a gap between the two panels covering the main hatch. There were no watertight seals on the covers and no means to effectively secure the hatch covers to the coaming. During the events culminating in the sinking of the vessel, the hatch covers lifted off the coaming leaving the hold open. The bilge pumping system was not capable of controlling the flooding. After being downflooded, the vessel eventually lost all reserve buoyancy and sank. 3.2 Findings as to Risk The vessel was taken to the south shore because the price for scallops there was higher than on the north shore, which increased the vessel's exposure to bad weather. The practice on the BRIERMIST was not to secure the panels or cover them with a tarpaulin. The vessel was not equipped with a water level detector to give early warning of flooding. Despite the risk of downflooding, no modifications to the hatch covers had been made by the owners over the years. Over the 17 years the vessel was in service and in five regular inspections, neither the owners nor the regulator required the hold to be equipped with a watertight, effectively secured cover. During the events leading up to the sinking of the vessel, the master reported the deteriorating conditions but did not state that the vessel was in distress or required assistance. The vessel did not carry an emergency position indicating radio beacon which, if operated, would alert the search and rescue system and provide ongoing information with respect to the vessel's position. The liferaft, which was not recovered and presumably sank with the vessel, could not deploy automatically as it was not fitted with a hydrostatic release and, as a result, did not provide life-saving support to persons in the water. The seamen had not been trained in marine emergency duties. Such training would have increased their knowledge of emergency procedures and the probability of successfully abandoning this vessel. The master-owner of the BRIERMIST had made major modifications and had not determined the effect of those modifications on the vessel's stability. 4.0 Safety Action 4.1 Action Taken 4.1.1 Coroner's Recommendations The coroner in charge of the inquest into the deaths of the five seamen of the BRIERMIST released his report on 21 January 2000. On the basis of the information gathered during his inquest, the coroner made a finding of violent accidental death. His report contains eight recommendations. The coroner recommended to Transport Canada (TC): That all commercial fishermen receive training in marine emergency duties (MED), and that this training be reviewed periodically with fishermen. That fishing vessels like the BRIERMIST be required to be fitted with a water level detector in the fish holds. That fishing vessels like the BRIERMIST carry an inflatable liferaft fitted with an automatic release mechanism. That vessels like the BRIERMIST have watertight and airtight hatch covers on deck, and that the existing regulations be enforced by TC inspectors. That fishing vessels like the BRIERMIST be required to be equipped with a Class I emergency position indicating radio beacon (EPIRB). That fishing vessels like the BRIERMIST be equipped with survival and floater suits for each crew member, and that emergency drills be conducted periodically with crews. That shipyards or other companies that perform work on fishing vessels like the BRIERMIST (work that increases the vessel's weight) inform Transport Canada Marine Safety (TCMS) of the name of the vessel on which the work has been performed. The coroner further recommended: That Fisheries and Oceans Canada inform TCMS regional offices of the presence of fishing vessels in their regions engaged in a fishing activity during hazardous navigation periods (which may vary from one fishing region to another in Canada) to facilitate the inspection of vessels during such periods. 4.1.2 Transport Canada Response TC provided the following explanations in response to the coroner's recommendations: Section 21 of the Crewing Regulations currently states that Every member of the complement of a ship shall, before the member has completed six months on board ships, obtain a certificate of the member's successful completion of training, at a recognized institution, in marine emergency duties with respect to basic safety (A-1). This section applies to all registered vessels other than pleasure craft. Hence, section 21 applies to all fishing vessels. However, it is important to note that an amendment has been submitted to delay the application of that section until 30 July 2002 for members of the complement of a fishing vessel who are not required to hold a certificate because the vessel does not make voyages beyond the limits of a fishing voyage Class II. A fishing voyage Class II is a voyage bounded in North America between longitude 03000' W and 18000' W and north of latitude 0600' N. This amendment and the delay occasioned by it are due to the fact that MED courses are not as readily available as they need to be. The submitted amendment is presently part of a group of amendments that have been processed through the required channels of regulatory change. It is expected that all the submitted amendments will become law by the end of 2000. The training requirements needed to be met under basic safety are defined as MED course A-1. This course is offered at all main marine training institutions. In order to meet the needs of those marine communities which do not have easy access to a marine training institution, some of the institutions are also equipped with a vehicle, provided by TCMS, that is fitted with all the required training equipment. All fishermen who have already taken an MED course will not be required to repeat any part of the MED training. This applies mainly to fishermen who hold a fishing vessel master's certificate. While TC agrees with the concept of fish hold high water level detectors on small fishing vessels, the feasibility of fitting such detectors and the subsequent proper operation of the detectors in the fish hold, considering the harsh ambient conditions in such a space, is a concern. The subject of high water level detectors along with the associated audible and visible alarms is currently an item of discussion with the Small Fishing Vessel Steering Committee. The subject of requiring liferafts on small fishing vessels and many other types of small vessels to be equipped with an automatic release mechanism (hydrostatic release unit) has been debated for some time. One of the major problems in fitting a hydrostatic release mechanism on the liferafts of any small vessel is that, in normal operating conditions, the decks of such vessels and the areas where liferafts are stowed may be subjected to seas washing over them. In many cases, the volume of water that washes over the area can be sufficient to activate the liferaft's hydrostatic release, thereby resulting in the loss of the liferaft. TCMS will continue to discuss the issue with the marine industry to find solutions to the problems. The current regulations for small fishing vessels already require that hatch covers be watertight. Subsection 23(2) of the Small Fishing Vessel Inspection Regulations (Chapter 1486) states that Hatchways on a fishing vessel shall be provided with efficient means for battening them down and making them watertight. TCMS is aware of the problems concerning the watertight integrity of hatch covers on small fishing vessels. As a result of the BRIERMIST occurrence, targeted inspections are now carried out on certified vessels to ensure, among other things, that all openings on fishing vessel decks are adequately protected. The BRIERMIST was certified for voyages of Home Trade Class III.[6] In 1999, TC has proposed, in modifications to the Ship Station Radio Regulations, that by 01 April 2001, all vessels of 8 m or more in length and of closed construction, on all Home Trade voyages (with the exception of Home Trade IV voyages in a Vessel Traffic Services (VTS) zone) be required to carry a very high frequency (VHF) radio with digital selective calling (DSC). Vessels fitted with radio navigation receivers will be required to interface the navigation receiver to the DSC transceiver so that an up-to-date position of the vessel will be transmitted if the distress alert button is activated. Vessels similar in size and voyage class to the BRIERMIST would be required to comply with these proposed requirements. There has been much discussion of requiring immersion suits on small fishing vessels. This issue is also currently under discussion within the Small Fishing Vessel Steering Committee. The issue of requiring immersion suits on small fishing vessels has always presented two main obstacles: Unlike a large fishing vessel, where such suits are required to be carried, a capsizing or a sinking of a small fishing vessel, in most cases, happens very quickly, as in the case of the BRIERMIST. Therefore, crew members, in many cases, do not have the advance warning time to don an immersion suit. Also, as immersion suits by their design make it nearly impossible for crew members to perform shipboard functions, a small fishing vessel crew member wearing an immersion suit may be restricted, due to the suit and the limited space on such a vessel, from performing functions which may be necessary to prevent the vessel from foundering. Due to the limited space on a small vessel, there is, in many cases, simply not enough room to store immersion suits. Also, because of the tight working conditions and the rough character of the work performed on such vessels, the incidence of damaging the immersion suits would be very high. Part V, subsection 377(2), of the Canada Shipping Act (CSA) states that, Where . . . any part of the hull, equipment or machinery has been altered . . . so as to affect its compliance with the regulations . . . the owner or master shall forthwith report the matter to the Chairman [of the Board of Steamship Inspection], . . . and the ship shall not go from any place in Canada until it has been re-inspected and a certificate issued in accordance with the conditions found to exist. Further to the requirements contained in the CSA, TCMS has previously issued numerous Ship Safety Bulletins (SSBs) addressing this subject, in particular the effect that some modifications have on the stability of the vessel. SSBs are a communication tool issued to a wide audience of the marine industry (vessel operators, owners, builders, designers, etc.) to alert them to potential hazardous situations or practices. Furthermore, it could prove difficult from a legislative point of view to require dockyards, shipyards and other companies that perform work on vessels to report that work to a TCMS office because TC's enforcement responsibilities and mandate are directly connected to ships and their crews, but do not extend to the marine infrastructure such as shipyards and ship repair facilities. TC will however continue to recommend to those types of facilities to inform the nearest TCMS office when modifications to a vessel are carried out. Furthermore, it could prove difficult from a legislative point of view to require dockyards, shipyards and other companies that perform work on vessels to report that work to a TCMS office because TC's enforcement responsibilities and mandate are directly connected to ships and their crews, but do not extend to the marine infrastructure such as shipyards and ship repair facilities. TC will however continue to recommend to those types of facilities to inform the nearest TCMS office when modifications to a vessel are carried out. 4.1.3 Inspection of Fishing Vessels In February 1999, a Marine Safety Advisory (MSA No. 03/99) was sent to TC pointing out the deficiencies found in the investigation. The advisory states that, when conducting inspections, TC inspectors often find fishing vessels having main hatch covers with deficiencies similar to those found on the BRIERMIST. Some inspectors have indicated that they sometimes have difficulty enforcing the regulations because the problem is so widespread and because of the expenditures the owners must incur to correct these deficiencies. These difficulties have resulted in some discrepancies in the application and enforcement of the Small Fishing Vessel Inspection Regulations respecting hold covers. Given the associated risks, it was suggested that the matter be discussed with TC regional offices with a view to ensuring more consistent enforcement of the regulations across the country. Finally, the MSA states that it would be advisable to inform fishermen and builders of small fishing vessels of the increased risk associated with non-watertight hold hatch covers. TC replied that the weathertight integrity of fishing vessel hold openings remains a constant concern for its inspectors, and that it has published several SSBs on the subject (Nos. 16/92, 4/87 and 1/83). TC notes that, after the quadrennial inspections of these vessels carried out by TCMS, it has no control over hold cover maintenance by the vessel owners. TC believes that new vessels are generally equipped with weathertight hold covers with proper closures, as required by the regulations. According to TC, most vessels inspected, with few exceptions, are equipped with proper closures. TC nevertheless notes that several small fishing vessels not subject to inspections may not be adequately protected. TC plans to target vessels deemed to be at risk under a special inspection program. 4.2 Action Required The sinking of the BRIERMIST demonstrates the risks to which small fishing vessel crews may be exposed. The main deficiencies brought to light in this occurrence are the watertightness of hatches, the detection of flooding in the fish hold and emergency training for fishermen. Furthermore, the lack of life-saving equipment, such as anti-exposure floater suits, EPIRBs and liferaft automatic release mechanisms, is likely to increase the risks of fatalities when mariners are forced to abandon fishing vessels. 4.2.1 Hatch Covers From 1975 to 1999, some 236 fishing vessels have been involved in fatal shipping accidents. Of those, 125 capsized or foundered, causing 260 fatalities. In 196 investigated Canadian fishing vessel accidents, about half involved downflooding due to inefficient, defective or ineffectively secured hatch covers and/or scuttle covers. Canadian Fishing Vessel Capsizing and Foundering Accidents Resulting in Loss of Lives--1975-1999[7] For example, on 10 April 1995, the vessel HILI-KUM (TSB report No. M95W0013) was being operated in following high winds and rough seas with the fish hold hatch cover not battened down. Because the custom-designed fish hold hatch covers were not used and the temporary plywood hatch cover was not watertight, seawater washing over the after deck poured into the hold. There is an unnecessary risk to fishing vessel crews unless they are provided with an effective means of battening down hatches and making them watertight. Further, the risk is compounded where the means of making the hatches watertight is not employed. The Small Fishing Vessel Inspection Regulations have stated the requirements to the industry, but the problem was evident on the BRIERMIST and these following other examples: During the summer of 1996, the TC (Laurentian Region) inspection service conducted checks of the les-de-la-Madeleine fishing fleet and found several tonnage and certification deficiencies. The deficiencies observed related to watertight bulkheads, flush-deck scuttles, bilge pumps, freeing ports and emergency exits. The watertightness of the closures on the decks of small fishing vessels like the BRIERMIST is seriously compromised when the hatch covers are not held in place efficiently by a locking system. The BRIERMIST occurrence shows how the absence of a securing system and lack of maintenance of watertight seals can have serious consequences. TC's efforts have not been entirely effective in achieving industry compliance with the safety requirement of ensuring that the fish holds can be made watertight. In its response to the coroner's Recommendation No. 4, TC has indicated that it is aware of the problems with the watertight integrity of some small fishing vessel hatch covers and that action will be taken to ensure that openings on fishing vessel decks are adequately protected. However, given the deficiencies noted over the past 10 years in the design, manufacturing, installation, maintenance and inspection of small fishing vessel hold closure systems, the Board is still very concerned about the loss of lives in this sector of the marine industry. Accordingly, the Board recommends that: The fishing industry and the Department of Transport give increased attention to small fishing vessel hatch covers to help ensure that these covers are watertight and can be effectively secured. M00-06 Assessment/Reassessment Rating: Satisfactory Intent 4.2.2 Liferaft Release Mechanisms The crew's chances of survival in an emergency depend on the capacity, reliability and availability of life-saving equipment. There are regulatory requirements which state that a fishing vessel like the BRIERMIST must be equipped with a liferaft which is to be stowed so as to permit manual release from its securing arrangements. However, if owners of small fishing vessels exceeding 12 m in length wish to carry two inflatable liferafts, then they must equip one of the rafts with a hydrostatic release.[9] Further, the Small Fishing Vessel Safety Manual, TP 10038,[10] recommends having the liferaft inspected and repacked and the hydrostatic release tested according to the requirements of the Canadian Coast Guard (CCG) and the manufacturer. This manual therefore contains valuable recommendations that are not prescribed in the regulations. More deficient liferafts have also been identified in the last five years suggesting that there is a significant number of inadequate life-saving survival craft aboard small fishing vessels.[11] In his inquest report, the coroner recommended that fishing vessels like the BRIERMIST carry an inflatable liferaft fitted with an automatic release mechanism. TC has indicated that it is going to continue to review this issue with the marine industry to find solutions to the problems. The Board has already expressed its concern that the absence of automatic release mechanisms on liferafts on small fishing vessels needlessly compromises the chances of survival of crews in an emergency at sea when the liferaft goes down with the vessel. As the chances of survival of fishermen on abandoning the vessel depend on launching the liferafts, and considering the extremely difficult conditions in which abandonments are often carried out on small fishing vessels, the Board is of the opinion that liferafts should be easy to release when the vessel sinks in order to allow the crew members to access the liferafts on abandoning ship. Accordingly, the Board recommends that: The Department of Transport alert builders and owners of fishing vessels to the need for the liferafts on all vessels to be stowed with a launching system fitted with a release mechanism that allows the inflatable liferaft to be easily released when the vessel sinks. M00-07 The Department of Transport examine the effectiveness of liferaft automatic release mechanisms to prevent premature activation of these mechanisms on small fishing vessels in rough sea conditions. M00-08 4.2.3 Emergency Position Indicating Radio Beacons (EPIRBs) In a distress situation where a vessel sinks and the EPIRB is deployed and emits a signal, the search and rescue (SAR) resources are alerted which allows them to initiate action. After approximately 90 minutes, they are able to have a reasonably accurate position. The signal includes an identifier which enables the SAR controller to have valuable information about the vessel and the owner. Further, as the SAR craft respond to the site, the beacon continues to send its position and can be homed in on, thus substantially reducing search time and improving the probability of survival. The Canadian regulations do not require all fishing vessels to be equipped with EPIRBs. A fishing vessel such as the BRIERMIST is not required to carry an EPIRB due to its length (13 m) and the fact that the vessel is limited to voyages not more than 20 miles from shore. Similarly, fishing vessels that are 20 m or more in length and voyage north of the latitudes of New York, New York, and Portland, Oregon, within 120 miles of shore and 200 miles between a suitable port of refuge, are also not required to carry an EPIRB. There is a requirement to carry an EPIRB only when a vessel is 20 m or longer and can voyage anywhere in North America, including the north shore of South America. Then, such a vessel is required to carry two EPIRBs that are readily accessible and stowed on each side of the vessel so they can be placed in survival craft. Of the fatal and non-fatal accidents since 1975, 592 fishing vessels less than 150 gross tons have capsized, foundered or were reported missing in Canadian waters resulting in 316 fatalities. The BRIERMIST had a gross tonnage of 45.8 and a length of 13 m, placing it within the 15 to 60 gross-ton range, in which there were 76 fatalities. The following figures provide a geographic presentation of the location of fatal shipping accidents showing that they occur close to shore. Figure 1 - Fatal shipping accidents involving Canadian fishing vessels in eastern Canada 1975-1999 Figure 2 - Fatal shipping accidents involving Canadian fishing vessels in western Canada 1975-1999 Fatalities resulting from shipping accidents represent about 72 per cent of the total number of fatalities in marine accidents involving fishing vessels. More than half of the fatalities in shipping accidents result from capsizing or foundering accidents; another 22 per cent involve accidents classed as other, mostly vessels that went missing (see Figure 3). Figure 3 - Shipping accidents fatalities by type of accidents In 1992, a CCG cost-benefit analysis for amendments to the EPIRB Regulations concluded that 214 deaths in 1990 were attributable to accidents involving vessels of various categories, including fishing vessels, that were not equipped with EPIRBs. Out of the 990 SAR missions involving fishing vessels between 8 and 12 m in length, only 6 vessels were carrying EPIRBs.[12] According to Canadian ship registration records, there are approximately 27,000 fishing vessels in Canada. The vast majority of small fishing vessels (83 per cent of the total) engaged on voyages in the territorial waters of Canada and beyond sheltered waters are not equipped with EPIRBs. In its report on the investigation into the sinking of the small fishing vessel 3J'S '93 on 23 September 1996 (TSB report No. M96M0128), the Board noted that the absence of an EPIRB on the vessel had played a role in the outcome of the occurrence as the vessel capsized with such a speed that the operator was not able to issue a distress message by VHF. In another occurrence, on 12 October 1994, the PATRICK ELIZABETH disappeared about 40 miles north-east of Bay Bulls, Newfoundland. After receiving the alert at 0936, Newfoundland daylight time, a SAR controller coordinated a search where a SAR aircraft, following search patterns based upon drift plots, found debris approximately eight hours later. None of the five crew members was found (TSB report No. M94N0021). Conversely, in the sinking of the CAPE ASPY off Nova Scotia on 30 January 1993, the EPIRB signal was picked up a few moments after the vessel sank, and the Halifax Rescue Coordination Centre was therefore able to undertake a SAR operation in less than 10 minutes. The saving of several lives has been attributed mainly to the automatically deploying EPIRB (TSB report No. M93M4004). The above accident record shows that fishermen continue to be exposed to risks even when operating close to the Canadian coast, resulting in accidents involving the loss of the vessel and the loss of lives. In such circumstances, the crew members have to rely on others being alerted to their distress and being aware of their position. Some key factors affecting SAR by reducing the search time and increasing the probability of survival are: a timely distress alert, an updated position of the vessel, survival craft, or person in the water, characteristics of the vessel such as size and colour, the name of the vessel, information about the crew (i.e. number). An EPIRB that will float free and activate automatically when the vessel sinks provides SAR personnel with this information. The coroner recommended that there should be a Class I EPIRB (float-free) fitted on fishing vessels like the BRIERMIST. TCMS responded by noting that such a vessel will be required to carry a VHF radio installation with DSC. Such an installation will be required to interface with the navigation receiver so that an up-to-date position of the vessel will be transmitted if the distress alert button is activated. This response addresses only part of the safety deficiency and has to be considered in conjunction with proposed amendments to the Small Fishing Vessel Inspection Regulations that are currently planned to come into force on 01 April 2001. The proposed amendments delete the requirement for EPIRBs on those vessels on unrestricted voyages about North America and require that such a vessel carry a search and rescue transponder (SART) such that it is accessible for immediate use and for placing in a survival craft. For those fishing vessels which are required to carry a SART, the International Maritime Organization (IMO) performance standards specify that the responder must be capable of being interrogated at a range of 5 M by a navigation radar and 30 M by an airborne radar providing limited information to the SAR responders. In an accident where a fishing vessel sinks, the crew members failing to activate their distress signal and relying solely on a SART would only have some limited capability to alert passing ships or aircraft of a distress situation. These changing regulatory requirements do not address the risks to which fishermen working in coastal areas are exposed. The VHF with DSC requires a power source, someone to activate it, and the information it provides is only as accurate as the last position which is fed from the navigation receiver. If the fishing vessel were the size of the BRIERMIST, there would be no ongoing position information if the vessel sank as there is no SART or EPIRB. The Board is of the opinion that all fishermen should have a distress-alerting capability that should not rely on human intervention. Further, fishermen forced into the water or survival craft should have the capability to continuously update their position to SAR coordinators and responders as the effects of wind and current cause them to drift. Therefore, the Board recommends that: The Department of Transport require small fishing vessels engaging in coastal voyages to carry an emergency position indicating radio beacon or other appropriate equipment that floats free, automatically activates, alerts the search and rescue system, and provides position updates and homing-in capabilities. M00-09 Assessment/Reassessment Rating: Satisfactory Intent 4.3 Safety Concerns 4.3.1 Water Level Detectors The flooding of the fish hold and afterpeak of the BRIERMIST gradually reduced the vessel's stability until the reserve buoyancy was eliminated and the vessel sank. Flooding of the hold poses a hazard that is the source of many fishing vessel accidents. The installation of a water level alarm system in a compartment below the waterline is an inexpensive way to detect flooding before the vessel's stability is compromised. The audible and visible alarm alerts the watchkeepers to search for and repair the source of the water ingress. As soon as it becomes clear that the flooding cannot be controlled, the crew must prepare to abandon ship. Early detection allows more time to prepare to abandon ship, thereby increasing the crew's chances of survival. In recent years, the inability to detect and plug leaks has caused the sinking of several fishing vessels. Such hazards were identified in the following occurrences: In addition, on 27 June 1990, off Labrador, the fishing vessel NORTHERN OSPREY sank because flooding of the engine-room was not detected in time (TSB report No. M90M4020). On 16 December 1990, the NADINE, a 37 m fishing vessel, sank by the stern in the Gulf of St. Lawrence. Two crew members were rescued; the bodies of six victims were recovered; and two crew members were reported missing (TSB report No. M90L3034). The Board determined that the NADINE sank because the openings on the after deck and in the transverse bulkheads were not secured. The suddenness of the sinking contributed to the loss of lives. In its report on that occurrence, the Board recommended that the Department of Transport require the installation of water level detectors in all compartments below the waterline on large fishing vessels (recommendation M94-06, issued May 1994). The BRIERMIST had no water level detector or alarm in the fish hold or the afterpeak. The absence of a water level detector and an audible and visible alarm on the bridge explains why the crew was slow in detecting the flooding. As the regulations do not require the installation of water level alarms in the various compartments of fishing vessels, the danger persists. In its response to the coroner's Recommendation No. 2, TC has indicated that it agrees with the concept of fish hold high water level detectors on small fishing vessels, and that the Small Fishing Vessel Steering Committee will examine the subject. However, as 10 years have gone by since the sinking of the NADINE without the changes recommended in 1994 having been made, the Board is still very concerned about the lack of progress on the installation of water level detection and alarm systems in compartments below the waterline of closed-construction fishing vessels. The Board will continue to assess the safety action taken by TC in this area. 4.3.2 Protection from Hypothermia and Drowning During most of the year in Canadian waters, protection against hypothermia is essential to survival. To face the climatic conditions prevailing in the estuary of the St. Lawrence River, personal life-saving equipment should both protect against the cold and provide flotation. Although lifejackets meet strict buoyancy standards and have the ability to turn an unconscious person onto his/her back in the water, they offer no protection against the cold. The survival time of a person immersed in cold water while wearing a lifejacket is often measured in minutes whereas a person wearing an anti-exposure worksuit can survive for several hours. The BRIERMIST carried only three personal flotation devices (PFDs) for the five seamen on board. One of the seamen found only had time to partly pull on his PFD. The other seaman recovered had time to grab a lifebuoy before abandoning the vessel. It is not known if the three missing seamen were able to find their lifejackets. The four main factors contributing to deaths in the fishing industry in Canada are falling overboard, or foundering, capsizing and sinking of the vessel. Often when the vessel sinks, the crew is forced to abandon ship. In such circumstances, protection from hypothermia is a major factor in survival. In January 1993, following the sinking of the scallop dragger CAPE ASPY, 10 survivors were found after spending three hours on a liferaft while another survivor was rescued from the icy sea about six hours after the sinking (TSB report No. M93M4004). These persons owe their lives to their immersion suits. Persons wearing such suits have been successfully rescued after 18 hours of immersion in cold water. The BRIERMIST was not required to carry this type of equipment. In December 1998, the coroner concluded that the deaths of the five crew members of the BRIERMIST were attributable to drowning following hypothermia due to immersion in icy water. The coroner deemed it imperative that such life-saving equipment be available for all seamen on board fishing vessels operating in cold water. In its response to the coroner's Recommendation No. 6, TC has explained why there have been delays in adopting such a measure even though the risk of accidents is greater on small vessels. In 1993, the Board recommended that TC expedite its revision of the Small Fishing Vessel Safety Regulations which would require the carriage of anti-exposure worksuits or survival suits by fishermen (recommendation No. M92-07, issued March 1993). The response to that recommendation was that the Small Fishing Vessel Steering Committee would consider anti-exposure suits as an alternative to standard lifejackets when it would work on the revision of the Small Fishing Vessel Regulations. Since more than eight years have gone by without the recommended changes being made, the Board is very concerned about the slow progress in this area and is also concerned that more than 10 fishermen lose their lives every year by drowning and hypothermia. The number of deaths by drowning is not decreasing despite the attempts by the CCG and TC to inform fishermen about the benefits of carrying worksuits that protect from cold and drowning hazards. Such equipment is available on the market; however, the safety message does not appear to be reaching fishermen. The Board therefore believes that more energetic action is necessary. It is noted that anti-exposure suits are required on large fishing vessels and that TCMS agrees that there is a need for each person to be equipped with an immersion suit on board vessels operating in waters where hypothermia can greatly reduce an individual's survival time.[13] The Board believes that the need for an immersion suit is equal or greater on small fishing vessels than on other types of vessels, and that TC should review Recommendation M92-07 with a view to expediting action required to address this deficiency. 4.3.3 Marine Emergency Duties (MED) Training None of the five crew members of the BRIERMIST was required to take any MED training. The decision to abandon a small fishing vessel at sea is often taken very quickly, and sometimes in panic. It may be possible to don suits protecting from hypothermia or immersion suits more quickly in an emergency if the crew has practised donning such suits during ship abandonment drills. Drills also provide an opportunity to show the crew how to stow and don immersion suits and launch liferafts. It is easier to take whatever corrective measure is necessary before a real emergency occurs. The Board has determined that the lack of training in survival techniques contributed to the loss of several lives. Following its investigation into the sinking of the Canadian fishing vessel STRAITS PRIDE II (TSB report No. M90N5017), the Board recommended that the Department of Transport ensure that personnel who regularly crew closed-construction fishing vessels receive formal training in life-saving equipment and survival techniques (recommendation M92-06, issued March 1993). TC advised that it had developed a draft amendment to the Canada Shipping Act along the lines of this recommendation. Following the sinking of the PACIFIC BANDIT on 11 February 1995 (TSB report No. M95W0005), the Board recommended that the Department of Transport examine ways to encourage crews of small fishing vessels to train in the use of life-saving equipment (recommendation M96-15, issued December 1996). In 1998, TC set up a working group on fishing vessel safety. In the meantime, the lack of knowledge of life-saving and survival techniques continues to compromise the chances of survival of fishermen in an emergency. In its response to the coroner's Recommendation No. 1, TC has noted that every member of a fishing vessel's crew will have to successfully complete MED training with respect to basic safety (A-1); however, this is not to apply to fishermen until 30 July 2002 as there are problems associated with the availability of training. The Board notes that, in the Crewing Regulations, this important provision was originally to apply to fishermen on 30 July 2000 and is therefore concerned that there may be further delays in its implementation.